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Acupuncture and assisted reproductive technology

  1. Ying C Cheong1,*,
  2. Sarah Dix2,
  3. Ernest Hung Yu Ng3,
  4. William L Ledger4,
  5. Cindy Farquhar5

Editorial Group: Cochrane Menstrual Disorders and Subfertility Group

Published Online: 26 JUL 2013

Assessed as up-to-date: 22 JUL 2013

DOI: 10.1002/14651858.CD006920.pub3


How to Cite

Cheong YC, Dix S, Hung Yu Ng E, Ledger WL, Farquhar C. Acupuncture and assisted reproductive technology. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD006920. DOI: 10.1002/14651858.CD006920.pub3.

Author Information

  1. 1

    University of Southampton, Obstetrics and Gynaecology, Southampton, UK

  2. 2

    Princess Anne Hospital, Obstetrics and Gynaecology, Southampton, UK

  3. 3

    University of Hong Kong, Queen Mary Hospital, Department of Obstetrics and Gynaecology, Hong Kong, Hong Kong, Hong Kong

  4. 4

    University of New South Wales, School of Women's & Children's Health, Randwick, NSW, Australia

  5. 5

    University of Auckland, Obstetrics and Gynaecology, Auckland, New Zealand

*Ying C Cheong, Obstetrics and Gynaecology, University of Southampton, Level F, Princess Anne Hospital, Coxford Road, Southampton, SO16 5YA, UK. yingcheong@hotmail.com. Y.Cheong@soton.ac.uk.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 26 JUL 2013

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Characteristics of included studies [ordered by study ID]
Andersen 2010

MethodsRandomised controlled trial of fertility patients in Denmark


ParticipantsPatients (n = 635) scheduled for embryo transfer were randomised into acupuncture according to the principles of Traditional Chinese Medicine (n = 314) or placebo acupuncture (n = 321).

The average age of the two groups of women was 31 years and the average body mass index (BMI) was 22.5 for both groups. There were similar numbers of previous IVF/ICSI cycles and similar proportions of causes of infertility between both groups.


InterventionsNeedle acupuncture or placebo acupuncture using Strietberger placebo needle for 25 minutes before and after embryo transfer; performed by nurses who were professional acupuncturists or by nurses who had received instruction and training by the acupuncturists prior to the trial


OutcomesOngoing pregnancy rate, implantation and pregnancy rates, live birth rates


Assisted conception protocolsStandard, long protocol GnRH down-regulation and the follicle stimulating hormone (FSH) or human menopausal gonadotrophin (hMG)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom sequence generation – LOW RISK - ‘the sequence of cluster randomization was based on a computer-generated list’

Allocation concealment (selection bias)Unclear risk‘nurses did the randomization with the sealed envelope technique’

Blinding (performance bias and detection bias)
All outcomes
Low riskSequence allocation was performed by nurses and the procedure was performed blinded to patients and the clinician performing ET

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo patients lost to follow up

Selective reporting (reporting bias)Low riskNone known

Other biasLow riskNone known

Benson 2006

MethodsRandomised controlled trial of fertility patients in US; abstract only


ParticipantsPatients (n = 258) who had been scheduled for ET were randomised into needle acupuncture (n = 53), laser acupuncture (n = 53), sham laser acupuncture (n = 52), relaxation treatment (n = 50) and no treatment (n = 50). For the purpose of this meta-analysis, only the results from the needle acupuncture and no treatment groups were used.

There were no details on the demographics as abstract only available


InterventionsNeedle acupuncture performed for 25 minutes before and after embryo transfer versus no intervention control group. There were no details on the qualifications of the acupuncturists as abstract only available


OutcomesClinical pregnancy rate


Assisted conception protocolsProtocol breakdown not provided


NotesEmailed authors for LBR but no reply


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskAbstract only; sequence generation not stated.

Allocation concealment (selection bias)Unclear riskAbstract only; allocation concealment not stated.

Blinding (performance bias and detection bias)
All outcomes
High riskNo sham needle group used, therefore blinding not possible

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk258 participants randomized but authors did not state the number of participants that completed the study.

Selective reporting (reporting bias)Unclear riskDid not report live birth

Other biasLow riskNone known

Craig 2007

MethodsMulticentre randomised control trial undertaken in the US; abstract only


Participants107 patients undergoing IVF randomised women into two groups: one with acupuncture treatment (n = 48) and one without (n = 46).

There were no details on demographics as this report was presented as an abstract


InterventionsAcupuncture performed for 25 minutes before and after embryo transfer, against no intervention control group.There were no details on the qualifications of the acupuncturists as abstract only available.


OutcomesOngoing and clinical pregnancy rate


Assisted conception protocolsProtocol breakdown not provided


NotesNo information provided by authors


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskAbstract only; sequence generation not stated

Allocation concealment (selection bias)Unclear riskAbstract only; allocation concealment not stated.

Blinding (performance bias and detection bias)
All outcomes
High riskNo sham acupuncture control used

Incomplete outcome data (attrition bias)
All outcomes
Low risk107 participants randomized, 94 completed the study. 10 IVF cycles cancelled, 3 patients withdrew.

Selective reporting (reporting bias)Unclear riskDid not report live birth

Other biasLow riskNone known

Dieterle 2006

MethodsRandomised controlled trial, fertility patients in clinic in Germany


Participants225 patients randomised: 116 to treatment and 109 to placebo. Treatment included placing Chinese herbs in patients' ears. No losses to follow up. Placebo treatment at sites that will not affect fertility, but physicians who were performing ET were blinded.

The average age (± SD) of the study group (n = 116) was 35.1 years (± 3.8) compared to 34.7 years (± 4) for the placebo group (n = 109). There were no statistical differences in the body mass index (BMI), causes of subfertility, and number of previous cycles between the study and control groups.


InterventionsTreatment included acupuncture + Chinese herbs in ears versus control group of acupuncture at sites that are not believed to affect fertility. The intervention was performed for 30 minutes after embryo transfer and again 3 days later. All acupuncture was performed by the same practitioner


OutcomesLive birth rate, clinical pregnancy rates and ongoing clinical pregnancy rates


Assisted conception protocolsStandard, long protocol GnRH down-regulation and the follicle stimulating hormone (FSH) or human menopausal gonadotrophin (hMG)


NotesPlacebo group did not have drugs placed in ears


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot stated in the manuscript

Allocation concealment (selection bias)Unclear risk‘randomised with sealed randomization envelopes’ but not stated if these envelopes where opaque or sequentially numbered.

Blinding (performance bias and detection bias)
All outcomes
Low riskUse of placebo treatment in control group

Incomplete outcome data (attrition bias)
All outcomes
Low risk225 participants randomized; none lost to follow up.

Selective reporting (reporting bias)Unclear riskNot known whether LBR a prestated outcome

Other biasLow riskNone known

Domar 2009

MethodsRandomised controlled trial of fertility patients in the US


Participants150 patients recruited and randomised to either needle acupuncture (n = 78) and no treatment (n=68).

The average age of the two groups of women was 36 years, with similar numbers of previous IVF cycles in the two groups.


InterventionsAcupuncture performed by an acupuncturist 25 minutes before and after embryo transfer versus no treatment control


OutcomesClinical pregnancy rate


Assisted conception protocolsProtocol breakdown not provided


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk‘randomisation was accomplished by using a computer-generated random numbers table’

Allocation concealment (selection bias)Unclear riskNot stated in the manuscript

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind as control group had no intervention

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk146 participants randomized but number completed not reported.

Selective reporting (reporting bias)Unclear riskNo LBR outcomes reported.

Other biasLow riskNone known

Fraterelli 2008

MethodsRandomised controlled trial of fertility patients in the US; abstract only


Participants1000 patients randomised to five arms: needle acupuncture (n = 200), laser acupuncture (n = 202), sham laser acupuncture (n = 198), relaxation (n = 203) and non-treatment group (n = 197).

No demographics breakdown given but stated no difference between groups


InterventionsTwo treatment arms (laser and needle acupuncture) and three control arms (sham laser acupuncture, relaxation and non-treatment). For the purpose of this meta-analysis, only the results from the needle acupuncture and no treatment groups were used


OutcomesChemical and clinical pregnancy rate


Assisted conception protocolsProtocol breakdown not provided


NotesOnly needle acupuncture versus control are relevant to this review


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskAbstract only, no randomisation details given

Allocation concealment (selection bias)Unclear riskAbstract only, no details given

Blinding (performance bias and detection bias)
All outcomes
High riskControl group received no treatment

Incomplete outcome data (attrition bias)
All outcomes
Unclear risknot stated if all participants randomized completed the study

Selective reporting (reporting bias)Unclear riskNo LBR outcomes reported.

Other biasLow riskNone known

Gejervall 2005

MethodsOpen, randomised single-centre trial performed at the IVF unit of Reproductive Medicine at Sahlgrenska University Hospital in Goteborg


ParticipantsThere were 160 women randomised in the study: 80 to the EA (electro-acupuncture) group and 80 to the CA (conventional acupuncture) group.

The average age of the women (± SD) in the control group (n = 80) was 33.9 years (± 3.7) compared to 33.2 years (± 3.6) in the intervention group; the average number of IVF cycles performed was 1.56 (± 0.93) compared to 1.48 (± 0.93). The majority of women had male factor or unexplained subfertility.


InterventionsThe study compared electro-acupuncture at the time of oocyte retrieval (EA group) with conventional analgesia (intravenous alfentanil). Both groups also had a paracervical block performed. Electro-acupuncture was performed by midwives who had been trained in the IVF unit.


OutcomesWellbeing was evaluated with the State Trait Anxiety Inventory (STAI). Pain and subjective expectations and experiences were recorded on a visual analogue scale (VAS). Time and drug consumption were recorded

Pregnancy rate was recorded as secondary outcome


Assisted conception protocolsStandard, long protocol GnRH down-regulation and the follicle stimulating hormone (FSH) or human menopausal gonadotrophin (hMG)


NotesStudy designed to assess effectiveness of acupuncture as an analgesic


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk‘randomisation was performed by the study coordinator according to a computerized list’

Allocation concealment (selection bias)Unclear riskNo details given

Blinding (performance bias and detection bias)
All outcomes
High riskConventional analgesia of I.V. alfentanil used as control analgesia. Therefore both participants and personnel not blinded. Not stated if assessor was blinded.

Incomplete outcome data (attrition bias)
All outcomes
Low risk160 women randomized; 2 lost to follow up.

Selective reporting (reporting bias)Unclear riskNo LBR outcome reported.

Other biasLow riskNone

Ho 2009

MethodsRandomised study performed at the IVF centre of China Medical University Hospital in Taiwan


ParticipantsA total of 44 women were enrolled in the study: 30 were randomised to acupuncture group and 14 to the control (no-acupuncture group).

The two groups were described as comparable for demographics including age and cause of infertility


InterventionsThe study compared electro-acupuncture (twice a week for two weeks, from cycle day 2 to the day prior to oocyte retrieval) with no acupuncture around the time of oocyte retrieval


OutcomesOutcome measures studied were clinical pregnancy and the pulsatility index (PI) of left and right uterine arteries


Assisted conception protocolsProtocol breakdown not provided


NotesThe study was designed to assess the impact of acupuncture on uterine artery blood flow and clinical pregnancy rate


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot stated

Allocation concealment (selection bias)Unclear risk‘randomly assigned to one of the two groups by selection of a sealed envelope.’

Blinding (performance bias and detection bias)
All outcomes
High riskControl group received no treatment

Incomplete outcome data (attrition bias)
All outcomes
High risk30 randomised to acupuncture group, and 26 to control group (but 12 in the control group dropped out), leaving 30 in the acupuncture group and only 14 in the control group.

Selective reporting (reporting bias)Unclear riskNo LBR outcome data reported.

Other biasLow riskNone known

Humaidan 2004

MethodsRandomised trial of fertility patients in Denmark


Participants200 patients randomised to either electro-acupuncture (n = 100) or conventional analgesia (n = 100) at the time of oocyte retrieval. Both groups also received a para-cervical block.


InterventionsElectro-acupuncture at the time of oocyte retrieval, given by specially trained nurses, versus conventional analgesia control (benzodiazepine, alfentanil)


OutcomesVAS scale
Clinical pregnancy rate


Assisted conception protocolsProtocol breakdown not provided


NotesStudy designed to assess effectiveness of acupuncture as an analgesic


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDetails not stated

Allocation concealment (selection bias)Low riskAdequate: randomisation using sealed unlabelled envelopes containing a study number

Blinding (performance bias and detection bias)
All outcomes
Low risk‘doctors and patients are blinded to the arm of treatment’.

Incomplete outcome data (attrition bias)
All outcomes
Low risk160 participants randomized; 8 in total withdrew from the study.

Selective reporting (reporting bias)Unclear riskLBR not a prestated outcome

Other biasLow riskNone known

Madaschi 2010

MethodsRandomised controlled trial of fertility patients in Brazil


Participants416 patients stratified according to age and then randomised to either acupuncture group (n = 208) or control with no acupuncture (n = 208)


InterventionsNeedle acupuncture 25 minutes before and after embryo transfer versus no acupuncture control. Intervention performed by the same practitioner in all cases

There was no statistically significant difference between the two groups for demographic characteristics. The average age (± SD) in the acupuncture group was 35.3 (± 4.7) compared to 34.6 (± 4.6) in the control group (p = 0.103). The average BMI in the acupuncture group was 22.4 (± 3.8) compared to 22.4 (± 2.9) in the control group (P = 0.951)

The main causes of subfertility were ovarian disorders and male factor with no statistical significance between both groups for any cause of subfertility


OutcomesPregnancy rate, implantation rate, abortion rate and live birth rate


Assisted conception protocolsStandard, long protocol GnRH down-regulation and the follicle stimulating hormone (FSH) or human menopausal gonadotrophin (hMG)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk‘patients were randomized before the beginning of the ovarian stimulation according to computer generated randomized numbers ‘

Allocation concealment (selection bias)Unclear riskmethod of allocation concealment not reported

Blinding (performance bias and detection bias)
All outcomes
High riskControl group had no treatment. It was not stated if the clinicians or the assessors of the study were blinded.

Incomplete outcome data (attrition bias)
All outcomes
Low risk416 participants were randomized; no drop out noted.

Selective reporting (reporting bias)Unclear riskLBR not a prestated outcome.

Other biasLow riskNone

Moy 2011

MethodsRandomized controlled trial of fertility patients in US


Participants160 patients undergoing IVF ± ICSI were randomised to either true acupuncture (n = 87) or sham acupuncture (n = 74)

The average age (± SD) in the true acupuncture group was 33.3 (± 0.307) years compared to 33.16 (± 0.334) years in the sham acupuncture group. There was no statistically significant difference in BMI or infertility diagnosis between the two groups, with the leading causes of infertility being male factor, ovarian dysfunction and unexplained.


InterventionsTrue (needle) acupuncture performed by hospital employed licensed acupuncturists versus sham placebo acupuncture. Both interventions performed for 25 minutes before and after embryo transfer


OutcomesClinical pregnancy rate and clinical symptoms during embryo transfer


Assisted conception protocolsProtocol breakdown not provided


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskpatients were randomized using a ‘random number generator’

Allocation concealment (selection bias)Low riskUse of 'sealed, sequentially numbered, opaque envelopes’.

Blinding (performance bias and detection bias)
All outcomes
Low riskControl group was allocated to Sham acupuncture. The physicians and patients were blinded to the randomization until the conclusion of the study.

Incomplete outcome data (attrition bias)
All outcomes
Low risk160 participants were randomized; 1 lost to follow up

Selective reporting (reporting bias)Unclear riskLBR outcome data not reported.

Other biasLow riskNone

Paulus 2002

MethodsRandomised controlled trial in fertility clinic in Germany


Participants160 patients randomised: 80 to treatment and 80 to no intervention control.

The age of the women (± SD) in the control group (n = 80) was 32.1 years (± 3.9) compared to 32.8 years (± 4.1) in the acupuncture group (n = 80). In the control group the average number of previous cycles was 2.0 (± 2.0) versus 2.1 (± 2.1) in the treatment group.

Most women had tubal disease, followed by male factor infertility then polycystic ovarian disease. These were in equal portions in both the study and control groups.


InterventionsAcupuncture performed by "well-trained examiners" 25 min before and after embryo transfer for treatment group; auricular acupuncture also performed on the treatment group


OutcomesClinical pregnancy rates


Assisted conception protocolsProtocol breakdown not given


NotesSame authors as Paulus 2003 but different group of patients


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer generated randomisation

Allocation concealment (selection bias)Unclear riskNot stated how the allocation was carried out.

Blinding (performance bias and detection bias)
All outcomes
High riskControl group had no treatment. Not stated if clinicians or assessors were blinded.

Incomplete outcome data (attrition bias)
All outcomes
Low risk160 randomised; no drop out.

Selective reporting (reporting bias)Unclear riskNot known whether LBR a prestated outcome

Other biasLow riskNone

Paulus 2003

MethodsRandomised placebo-controlled trial; abstract only


ParticipantsPatients were divided into two groups by random selection: embryo transfer with verum acupuncture (n = 100) and embryo transfer with placebo needling (n = 100).

No demographic details presented


InterventionsAcupuncture or sham acupuncture performed for 25 minutes before and after embryo transfer. In the control group (n=100) a placebo needle set was used without penetrating the skin, but at the same acupoints and after the same scheme


OutcomesClinical pregnancy rates


Assisted conception protocolsProtocol breakdown not given


NotesOnly included women with good embryos


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskcomputer generated randomisation

Allocation concealment (selection bias)Unclear riskAbstract only, not stated

Blinding (performance bias and detection bias)
All outcomes
Low riskControl group had placebo needling.

Incomplete outcome data (attrition bias)
All outcomes
Low risk100 participants were randomized. No drop out reported.

Selective reporting (reporting bias)Unclear riskNot known whether LBR a prestated outcome

Other biasLow riskNone

Sator-K 2006

MethodsRandomised controlled trial in fertility clinic in Austria


ParticipantsPatients were randomised in proportions of 1:1:1 to treatment with electro-acupuncture (n = 32), auricular acupuncture without electrical stimulation (n = 32) or a control group without needles or electrical stimulation (n = 30).

The mean ages (± SD) of the women undergoing IVF treatment in the group receiving electro-acupuncture with remifentanil (EA), acupuncture with remifentanil (A), and remifentanil with placebo (CO) were 33.3 years (± 1.7), 34.2 years (± 1.1) and 33.9 years (± 1.9), respectively. There were no differences in the number of failed cycles or causes of subfertility.


InterventionsEA, or EA with electrical stimulation or control of conventional analgesia (remifentanil) at the time of oocyte retrieval


OutcomesPain intensity and subjective well being were assessed using a visual analogue scale Nausea and tiredness were also assessed using a visual rating scale
Analgesic drug requirements during the entire study period


Assisted conception protocolsProtocol breakdown not provided


NotesStudy designed to assess effectiveness of acupuncture as an analgesic

Each P-Stim™ was programmed by an independent technician for electrical stimulation or no stimulation before the study. To ensure blinding of the investigator, each P-Stim™ was packed in a non-transparent case in which the respective permanent needles or adhesive tapes were also included. The packages were numbered consecutively, according to the randomisation list. Patients and investigators were blinded to the randomisation


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskcomputer generated sequence randomisaton

Allocation concealment (selection bias)Unclear risk‘Randomisation was concealed until at least 30 patients were randomized.’ ‘Patients and investigators were blinded to the randomisation’. Method of allocation concealment not clearly reported

Blinding (performance bias and detection bias)
All outcomes
High riskControl group had traditional I.V. pain relief.

Incomplete outcome data (attrition bias)
All outcomes
Low risk94 were randomized. 1 drop out.

Selective reporting (reporting bias)Unclear riskLBR outcome not reported.

Other biasLow riskNone known

Smith 2006

MethodsRandomised controlled trial in fertility clinic in Australia


Participants228 randomised, 36 excluded: 110 in treatment group and 118 in control group.

The average age of the control group (± SD) was 35.9 years (± 4.7) versus 36.1 years (± 4.8) in the study group; there were no differences in the number of previous treatment cycles, BMI, duration of subfertility.


InterventionsAll women had 3 sessions: day 9 of stimulation, immediately before ET, and immediately after ET. For the sham acupuncture group a sham needle was used close to but not on the treatment point


OutcomesClinical pregnancy rates


Assisted conception protocolsProtocol breakdown not provided


NotesAfter 3rd session, 24 in treatment group and 10 in control group guessed their allocation group correctly


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk‘randomization was in balanced, variable blocks of random size prepared by a researcher not involved in the trial’.

Allocation concealment (selection bias)Unclear riskNot stated specifically

Blinding (performance bias and detection bias)
All outcomes
Unclear riskControl groups had placebo needles (Streitberger) although after the 3rd session, 24 in the treatment group and 10 in the control group guessed their allocation group correctly.

Incomplete outcome data (attrition bias)
All outcomes
High risk228 subjects were randomized. 36 women had to be withdrawn (15%).

Selective reporting (reporting bias)Unclear riskLBR data not reported.

Other biasLow riskNone known

So 2009

MethodsRandomised controlled trial of fertility patients in Hong Kong


Participants370 patients undergoing assisted reproductive treatment randomised to either acupuncture (n = 185) or placebo acupuncture arms (n = 185).

The median age (interquartile range) in the acupuncture and placebo groups respectively was 36 (33 - 38) and 36 (34 - 38). Mean BMI (± SD) was similar at 21.6 (± 2.1) and 21.7 (± 2.7) kg/m2 for acupuncture and placebo groups respectively.

Both groups were comparable in terms of duration of infertility, cause of infertility, previous experience of acupuncture and smoking habit


InterventionsNeedle acupuncture or placebo needle acupuncture for 25 minutes before and after embryo transfer. Intervention performed by a certified Chinese acupuncturist with a degree in Chinese Medicine and 3 years experience


OutcomesPregnancy rate, clinical pregnancy rate, live birth rate, miscarriage rate


Assisted conception protocolsStandard, long protocol GnRH down-regulation and the follicle stimulating hormone (FSH) or human menopausal gonadotrophin (hMG)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskParticipants were randomized by a computer generated randomization list

Allocation concealment (selection bias)Low riskSealed opaque envelopes from the list used. ‘The sequence of randomization was concealed until interventions were assigned.’

Blinding (performance bias and detection bias)
All outcomes
Low risk‘patients, clinical staff involved in the care of patients and embryologist were blinded to the treatment group assigned’. The codes were only revealed after the completion of the entire study. Control group also had placebo needles.

Incomplete outcome data (attrition bias)
All outcomes
Low risk370 participants randomized; all completed the study.

Selective reporting (reporting bias)Low riskNone known.

Other biasLow riskNone known

So 2010

MethodsRandomised controlled trial of fertility patients undergoing frozen embryo transfer in Hong Kong


Participants226 patients randomised to either real (n = 113) or placebo acupuncture (n=113).

The median age at thawing was 36 (34 - 38) and 36 (34 - 39) years for real and placebo acupuncture respectively. The BMI, duration and cause of infertility and previous experience of acupuncture were also comparable between the two groups.


InterventionsNeedle acupuncture according to TCM principles or placebo acupuncture with Streitberger's sham placebo needles. Intervention performed by a certified Chinese acupuncturist with a degree in Chinese Medicine and 3 years experience


OutcomesOverall pregnancy rate, clinical pregnancy rate, ongoing pregnancy rate, live birth rate


Assisted conception protocolsStandard, long protocol GnRH down-regulation and the follicle stimulating hormone (FSH) or human menopausal gonadotrophin (hMG)


NotesMore patients in placebo group correctly guessed their randomisation compared to the true acupuncture group


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskparticipants were randomized by a computer generated randomization list

Allocation concealment (selection bias)Low riskSealed opaque envelopes from the list was used. ‘The sequence of randomization was concealed until interventions were assigned.’

Blinding (performance bias and detection bias)
All outcomes
Low risk‘patients, clinical staff involved in the care of patients and embryologist were blinded to the treatment group assigned’. The codes were only revealed after the completion of the entire study. Control group also had placebo needles.

Incomplete outcome data (attrition bias)
All outcomes
Low risk226 participants randomized. All completed the study.

Selective reporting (reporting bias)Low riskLBR available.

Other biasLow riskNone known

Stener-Victorin 1999

MethodsRandomised controlled trial, conducted in Sweden


Participants150 women undergoing IVF and ET were randomised to receive either electro-acupuncture and a paracervical block or alfentanil analgesia and a paracervical block.

The mean ages (range) of the study and control groups were 33.3 years (25 to 42) and 34.4 years (25 to 46). There was no difference in the two groups in terms of the cause of subfertility and the number of previous cycles.


InterventionsAcupuncture was performed at least 30 min before oocyte aspiration and PCB was placed at the start of the procedure and terminated directly after oocyte aspiration


OutcomesVAS, level of stress, implantation and pregnancy rates


Assisted conception protocolsProtocol breakdown not provided


NotesStudy designed to assess effectiveness of acupuncture as an analgesic


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"Each centre randomized its patients using sealed, unlabelled envelopes" - no further details

Allocation concealment (selection bias)Unclear risk‘sealed unlabelled envelope’

Blinding (performance bias and detection bias)
All outcomes
High riskControl group had traditional analgesia and t (Alfentanil + para cervical block) therefore blinding nor possible for clinicians or participants.

Incomplete outcome data (attrition bias)
All outcomes
Low risk150 women were randomized. 1 drop out.

Selective reporting (reporting bias)Unclear riskLBR data not reported.

Other biasUnclear risk"There is a possible bias in the study in that some of the women in the EA group were administered additional alfentanil during oocyte aspiration."

Stener-Victorin 2003

MethodsRandomised, controlled multi-centre trial in Sweden


ParticipantsWomen were randomised to either electro-acupuncture and a paracervical block or alfentanil and a paracervical block, as analgesia at the time of oocyte retrieval.

The mean age (range) in the study group was 32.9 years (22 to 38) and for the control group it was 32.9 years (25 to 38). The causes of infertility and number of IVF attempts did not differ between the two groups.


InterventionsWomen were given EA and a PCB of lidocaine hydrochloride during oocyte aspiration. Those women randomised to the alfentanil group were given alfentanil and a PCB during oocyte aspiration. The acupuncture stimulation began at least 30 min before oocyte aspiration


OutcomesVAS were used for pain assessment

Other variables recorded included abdominal pain, pain during placement of PCB, time of discomfort, adequacy of analgesia, stress level, nausea.

IVF outcomes were pregnancy rate (number of pregnancies per embryo transfer), implantation rate (number of gestational sacs per number of transferred oocytes) and on-going pregnancies (number of pregnancies per embryo transfer after the 16th week of gestation)


Assisted conception protocolsProtocol breakdown not provided


NotesStopped after interim analysis as results show no difference between two groups. Study designed to assess effectiveness of acupuncture as an analgesic


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risknot stated

Allocation concealment (selection bias)Unclear risk‘sealed unlabeled envelopes’

Blinding (performance bias and detection bias)
All outcomes
High riskControl group had paracervical block + Alfentanil and therefore blinding nor possible for clinicians or participants.

Incomplete outcome data (attrition bias)
All outcomes
Low risk286 randomized; 5 in the acupuncture group and 7 in the control group dropped out.

Selective reporting (reporting bias)Unclear riskNot known whether LBR a prestated outcome

Other biasLow riskNone

Westergaard 2006

MethodsRandomised controlled trial with patients from private clinic in Denmark


Participants273 women randomised: 87 allocated to no acupuncture and 95 to acupuncture on ET day only; 91 to acupuncture on ET and ET+2 days; 27 excluded,

The average ages of the three groups of women were: 37 years (27 to 45) in the control (n = 87) group, 37 years (24 to 45) in the group who had acupuncture on the day of ET (n = 95), and 37 years (27 to 45) for those with repeated acupuncture (ET + 2) (n = 91). There was no difference in the BMI between the three groups and about 67% of women had one or more attempts of IVF in the three groups.

The main causes of subfertility were described as male factor or unexplained


InterventionsAcupuncture was performed by specially trained nurses on patients undergoing ET on the day of ET, ET+2 and not on controls


OutcomesClinical pregnancy rate on ultrasound


Assisted conception protocolsStandard, long protocol GnRH down-regulation and the follicle stimulating hormone (FSH) or human menopausal gonadotrophin (hMG)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandomisation procedure handled by nurse not involved in study

Allocation concealment (selection bias)Unclear risk‘drawing of sealed envelope’ - no further details reported

Blinding (performance bias and detection bias)
All outcomes
High riskControl group had paracervical block, so blinding of the participants and personnel not possible.

Incomplete outcome data (attrition bias)
All outcomes
Low risk300 participants randomized. 27 dropped out leaving 273 participants for analysis.

Selective reporting (reporting bias)Unclear riskLBR data not prestated outcome.

Other biasLow risknone

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Chen 2004No reply to written and electronic request; study design, allocation concealment and outcomes unclear

Chen 2009No reply to electronic request; study design, methods and results not known

Chen 2012No outcomes of interest

Cui 2007No reply to electronic request; study design, methods and results not known

Cui 2011Inadequate randomisation process in study design, based on odd and even numbers

Evans 2005Lack details on pregnancy outcome, study design, allocation concealment and type of randomisation; no reply to written or electronic letters

Feliciani 2011No reply to electronic request; study numbers, randomisation process and outcomes unclear

Li 2009No reply to electronic request; study design, methods and results not known

Omodei 2010No reply to electronic request; study design, allocation concealment and outcomes unclear

Quintero 2004Lacks details on allocation concealment and randomisation, no reply to requests for details; crossover design

 
Characteristics of ongoing studies [ordered by study ID]
ACTRN12611000226909

Trial name or titleAcupuncture compared to sham acupuncture and standard care to improve live birth rates for women undergoing IVF: a randomised controlled trial

MethodsParallel design, randomised controlled trial

ParticipantsWomen aged less than 43 years, undergoing a fresh IVF or ICSI cycle, and restricted to women with the potential for a lower live birth rate defined as > 2 previous unsuccessful embryo transfers (fresh or frozen), and unsuccessful clinical pregnancies of quality embryos deemed by the embryologist to have been suitable for freezing by standard criteria

InterventionsNeedle or sham acupuncture for 1 hr on day 6-8 of the IVF cycle, plus two treatments on the day of the embryo transfer, 30 minutes before and after embryo transfer. Compared to no treatment control

OutcomesPrimary outcome: live birth - defined as the delivery of one or more living infants, greater than 20 weeks gestation or 400 grams or more birth weight.

Secondary outcomes:

1. clinical pregnancy defined as demonstration of fetal heart activity on ultrasound scan

2. miscarriage defined as a non viable pregnancy prior to 12 weeks gestation

3. quality of life

4. self efficacy

Starting dateRegistration: 02/03/2011

Contact informationCaroline Smith

Centre for Complementary Medicine Research University of Western Sydney Locked Bag 1797 Penrith South DC NSW 2751, Australia

Notes

IRCT201011275181N4

Trial name or titleEffects of acupuncture on outcome of in vitro fertilization and intracytoplasmic sperm injection (IVF/ICSI) in women with polycystic ovarian -

MethodsParallel design, triple blind, randomised controlled trial

ParticipantsInclusion criteria: women with the diagnosis of PCO (Rotterdam criteria) admitted to the clinic for IVF or ICSI treatments of infertility

InterventionsIntervention group 1: acupuncture based on Traditional Chinese Medicine, 5 sessions of thirty minutes. Intervention 2: Control group: (placebo) the same needles are used in 5 sessions of thirty minutes

OutcomesPrimary outcomes:

Embryo quality. Timepoint: 2 days after embryo transfer. Method of measurement: diagnosed by Embryologist and with embryological criteria.

Oocyte fertilisation rate. Timepoint: first day after embryo transfer. Method of measurement: diagnosed by embryologist and with embryological criteria

Oocyte metaphase 2. Timepoint: before and after embryo transfer. Method of measurement: diagnosed by embryologist and with embryological criteria

Secondary outcomes:

Biochemical pregnancy. Timepoint: 2 weeks after embryo transfer. Method of measurement: B-hCG

Clinical pregnancy. Timepoint: 4 weeks after embryo transfer. Method of measurement: sac observed in vaginal sonography

Miscarriage. Timepoint: <12 weeks after embryo transfer. Method of measurement: vaginal sonography

Take home baby. Timepoint: 9 months after embryo transfer. Method of measurement: Delivery

Starting dateRegistration 13/04/2011

Contact informationRashidi Batool

Address:

Tehran University of Medical Sciences, Valieasr Hospital and Imam Khomeini Hospital

Tehran

Islamic Republic of Iran

Notes

NCT00317317

Trial name or titleThe Effect of Acupuncture on Infertility With In-Vitro Fertilization (IVF) Patients

MethodsParallel design, single-blinded randomised controlled trial

ParticipantsInclusion criteria:

- Undergoing in vitro fertilisation protocol (both IVF and intracytoplasmic sperm injection - ICSI)

- Acupuncture naive

- Basal FSH <10

- Minimum age 21 years

InterventionsAcupuncture

OutcomesPrimary outcome: Clinical pregnancy rate

Secondary outcomes:

- B-endorphin levels

- Miscarriage rate

- Stress measurement

- Take home baby rate

Starting dateRegistration: 20/06/2006

Contact informationGrant Zhang, Ph.D.

Center For Integrative Medicine, University of Maryland

Notes

NCT01449396

Trial name or titleChinese Traditional Medicine Contribution to Improve In-vitro Fertilization (IVF) Results: Acupuncture in Embryo Transfer

MethodsParallel design, double-blinded, randomised controlled trial

ParticipantsInclusion criteria:

- 18 to 35 years old

- BMI 20-25

- Medical indication of intracytoplasmic sperm injection (ICSI) treatment to treat sterility

- No previous in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatments

- No previous experience of acupuncture treatments

- Make cause of sterility

- At least one high quality embryo on the day of uterine transfer

InterventionsAcupuncture versus bed rest

OutcomesPrimary outcome: pregnancy rate

Secondary outcomes:

- Analysis of the results of assisted reproductive cycle

- Determination of serum prolactin and 24h urine cortisol

- Endometrial vascularisation study

- Rating preconceived ideas about acupuncture

Starting dateRegistered: 04/10/2011

Contact informationMonica Romeu

romeu_monvil@gva.es

Notes

NCT01608048

Trial name or titleTranscutaneous Electrical Acupoint Stimulation to Improve Pregnancy Rates for Women Undergoing in Vitro Fertilization

MethodsSingle blind RCT

ParticipantsWomen undergoing IVF

InterventionsTranscutaneous electrical acupoint stimulation vs no acupuncture

OutcomesLive birth, clinical pregnancy

Starting dateMay 2012

Contact informationCui Hong Zheng, Doctor ph: 86-27-83663275 email: 635342693@qq.com

Notes

 
Comparison 1. Acupuncture around the time of oocyte retrieval versus control (sham, placebo, no acupuncture)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Live Birth Rate2464Odds Ratio (M-H, Fixed, 95% CI)0.87 [0.59, 1.29]

    1.1 Acupuncture versus Control
2464Odds Ratio (M-H, Fixed, 95% CI)0.87 [0.59, 1.29]

 2 Ongoing Pregnancy Rate2464Odds Ratio (M-H, Fixed, 95% CI)0.86 [0.58, 1.26]

    2.1 Acupuncture versus Control
2464Odds Ratio (M-H, Fixed, 95% CI)0.86 [0.58, 1.26]

 3 Clinical Pregnancy Rate6912Odds Ratio (M-H, Random, 95% CI)1.12 [0.78, 1.62]

    3.1 Acupuncture versus Control
6912Odds Ratio (M-H, Random, 95% CI)1.12 [0.78, 1.62]

 4 Miscarriage rate4262Odds Ratio (M-H, Fixed, 95% CI)0.79 [0.42, 1.47]

    4.1 Acupuncture versus Control
4262Odds Ratio (M-H, Fixed, 95% CI)0.79 [0.42, 1.47]

 
Comparison 2. Acupuncture on and around the day of ET versus control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Live Birth82505Odds Ratio (M-H, Random, 95% CI)1.22 [0.87, 1.70]

    1.1 Acupuncture versus Control (no sham/needling)
3849Odds Ratio (M-H, Random, 95% CI)1.55 [1.14, 2.12]

    1.2 Acupuncture versus Control (sham/needling)
51656Odds Ratio (M-H, Random, 95% CI)1.03 [0.67, 1.58]

 2 Ongoing pregnancy102807Odds Ratio (M-H, Random, 95% CI)1.10 [0.80, 1.52]

    2.1 Acupuncture versus Control (no sham/needling)
4924Odds Ratio (M-H, Random, 95% CI)1.08 [0.57, 2.07]

    2.2 Acupuncture versus Control (sham/needling)
61883Odds Ratio (M-H, Random, 95% CI)1.10 [0.74, 1.65]

 3 Clinical pregnancy143632Odds Ratio (M-H, Random, 95% CI)1.11 [0.87, 1.42]

    3.1 Acupuncture versus Control (no sham/needling)
71589Odds Ratio (M-H, Random, 95% CI)1.21 [0.84, 1.73]

    3.2 Acupuncture versus Control (sham/needling)
72043Odds Ratio (M-H, Random, 95% CI)1.04 [0.74, 1.46]

 4 Miscarriage6616Odds Ratio (M-H, Fixed, 95% CI)1.10 [0.73, 1.67]

    4.1 Acupuncture versus Control (no sham/needling)
2245Odds Ratio (M-H, Fixed, 95% CI)1.20 [0.57, 2.49]

    4.2 Acupuncture versus Control (sham/needling)
4371Odds Ratio (M-H, Fixed, 95% CI)1.06 [0.64, 1.76]

 5 Multiple gestation2795Odds Ratio (M-H, Fixed, 95% CI)1.32 [0.74, 2.35]

    5.1 Acupuncture versus Control (sham/needling)
2795Odds Ratio (M-H, Fixed, 95% CI)1.32 [0.74, 2.35]

 
Summary of findings for the main comparison. Acupuncture around the time of oocyte retrieval versus control (sham, placebo, no acupuncture) for women undergoing ART

Acupuncture around the time of oocyte retrieval versus control (sham, placebo, no acupuncture) for women undergoing assisted reproductive technology (ART)

Population: women undergoing ART
Intervention: Acupuncture around the time of oocyte retrieval versus control (sham, placebo, no acupuncture)

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlAcupuncture around the time of oocyte retrieval versus control (sham, placebo, no acupuncture)

Live birth rate357 per 1000326 per 1000
(247 to 418)
OR 0.87
(0.59 to 1.29)
464
(2 studies)
⊕⊕⊝⊝
low1,2
No significant difference in live birth rate was found between the two groups

*The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Neither study clearly reported method of random sequence generation, one did not clearly describe method of allocation concealment
2 Only two studies (n=464), wide confidence intervals.
 
Summary of findings 2. Acupuncture on the day of ET versus control for women undergoing ART

Acupuncture on the day of embryo transfer (ET) versus control for women undergoing assisted reproductive technology (ART)

Population: women undergoing ART
Intervention: Acupuncture on the day of ET versus control (sham, placebo, no acupuncture)

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlAcupuncture on the day of ET versus control

Live birth rate281 per 1000323 per 1000
(254 to 399)
OR 1.22
(0.87 to 1.7)
2505
(8 studies)
⊕⊕⊝⊝
low1,2,3
No significant difference in live birth rate was found between the two groups

*The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Two studies did not describe method of random sequence generation; six did not clearly describe method of allocation concealment
2 High statistical heterogeneity (I-squared =69%)
3 Wide confidence intervals
 
Table 1. Table 1. Summary of acupuncture points used.

Acupuncture pointsCraig 2007Westergaard 2006Dieterle 2006Paulus 2002 Paulus 2003 Andersen 2010; Domar 2009Madaschi 2010Ho 2009Moy 2011Smith 2006So 2009So 2010Stener-Victorin 1999Stener-Victorin 2003Gejervall 2005Humaidan 2004Sator-K 2006

Cv6 (Qi Hai)Y (before ET)Y

Cx6 (Neiguan)YYY

DU 20

(bai hui)
Y

GV 20 (Baihui)YY (around ET and ET + 2)YYYYYYYYY

Liv 2 (Xingjian)

Liv 3 (Taichong)YYYY

LI 4 (Hegu)YY ( ET + 2)Y (ET + 3)YYYYYYYYYYY

LI 10 (Shoushanli)Y

LR 3 (Taichong)YYYY

LU 7

(lieque)
Y

SP 6 (Sanyinjiao)YY ( ET + 2)Y (ET + 3)YYYYYYYYY

SP 8 (Diji)YYYYYYYY

SP 10 (Xuehai)YYYYYYYY

ST28Y

ST29 (Guilai)YY (ET and ET + 2)YYYYYYYYY

ST36 (Zushanli)YY (ET + 3)YYYYYYYYY

PC6 (Neiguan)YYYY

Ren 3 (Zhongji)Y (ET + 2)

RN 4 (Guanyuan)YY

RN6 (Qihai)YY

K3 (Tai Xi)Y (after ET)

K13 (Taxiu)Y (ET + 3)

K1 11(Henggu)YY

TE 5 (Weiguan)Y

EX-CA 1 (Zigong)Y

 
Table 2. Table 2. Summary of the treatment intended for the respective acupuncture points

Acupuncture pointsIntended treatment

Cx6 (Neiguan)Location: 2 cun above the transverse crease of the wrist, between the tendons of muscle palmaris longus and muscle flexor radialis.

Indications
Cardiac pain, palpitation, stuffy chest, pain in the hypochondriac region, stomach ache, nausea, vomiting, hiccups, mental disorders, epilepsy, insomnia, febrile diseases, irritability, malaria, contracture and pain in elbow and arm.

Traditional action
Opens the chest, regulates heart Qi and blood, regulates and clears the Triple Burner, calms the mind, regulates the terminal Yin, harmonizes the stomach.

GV 20 (Baihui)Location: on the midline of the head, 7 cun directly above the posterior hairline, approximately on the midpoint of the line connecting the apexes of the two auricles.

Indications
Headache, vertigo, tinnitus, nasal obstruction, aphasia by apoplexy, coma, mental disorders, prolapse of the rectum and the uterus.

Traditional action
Clears the mind, lifts the spirits, tonifies yang, strengthens the ascending function of the spleen, eliminates interior wind, promotes resuscitation.

Liv 2 (Xingjian)Location: on the dorsum of the foot between the 1st and 2nd toes, proximal to the margin of the web at the junction of the red and white skin.

Point associations:
Ying Spring point
Fire point

Actions and effects:
Generally, clears LV Fire - extreme irritability, red face, eyes, tongue.
Clears heat from the lower Jiao - burning urination.
Useful for "true heat, false cold" - lack of Qi flow to the extremities (cold hands or feet).

Liv 3 (Taichong)Location: on the dorsum of the foot in a depression distal to the junctions of the 1st and 2nd metatarsal bones.

Point associations:
Shu Stream point
Earth point
Yuan source point

Actions and effects:
Generally, resolves stagnation and tonifies Yin - balancing for all LV pathologies.
LV Qi Stagnation, LV Yang Rising - headaches, dizziness, canker sores.
Eye issues - blurred vision, red, swollen, painful eyes.
Menstrual issues from deficient blood, Yin, Qi, LV Qi stagnation - dysmenorrhea, amenorrhoea, PMS, breast tenderness.
Genital issues - pain and swelling, hernia, impotence, seminal emission.
Stagnation in the middle warmer - subcostal tension, chest or flank pain, swellings in the axillary region.
Digestive issues from LV attacking ST/SP - nausea, vomiting, constipation, diarrhoea with undigested food.
Calming point - anger, irritability, insomnia, anxiety.
With LI 4, four gates treatment - powerfully effects the flow of Qi and blood in the body.
Location: On the dorsum of the foot in a depression distal to the junctions of the 1st and 2nd metatarsal bones.

Point associations:
Shu Stream point
Earth point
Yuan source point

Actions and effects:
Generally, resolves stagnation and tonifies Yin - balancing for all LV pathologies.
LV Qi Stagnation / LV Yang Rising - headaches, dizziness, canker sores.
Eye issues - blurred vision, red, swollen, painful eyes.
Menstrual issues from deficient blood, Yin, Qi a/or LV Qi stagnation - dysmenorrhea, amenorrhoea, PMS, breast tenderness.
Genital issues - pain and swelling, hernia, impotence, seminal emission.
Stagnation in the middle warmer - subcostal tension, chest/flank pain, swellings in the axillary region.
Digestive issues from LV attacking ST/SP - nausea, vomiting, constipation, diarrhoea with undigested food.
Calming point - anger, irritability, insomnia, anxiety.
With LI 4, four gates treatment - powerfully effects the flow of Qi and blood in the body.

LI 4 (Hegu)Location: in the middle of the 2nd metacarpal bone on the radial side.

Precautions: no moxa, no needle in pregnancy.

Point associations:
Yuan source point
Entry point
Command point for face, nose, mouth and jaw

Actions and effects:
Releases the exterior for wind-cold or wind-heat syndromes.
Strengthens the wei qi, improves immunity.
Regulates the sweat glands, for excessive sweating tonify LI 4 then disperse KD 7 and vice versa.
Any problem on the face - sense organs, mouth, teeth, jaw, toothache, allergies, rhinitis, hay fever, acne, eye problems, etc.
Toothache use both LI 4 & ST 44 - LI for the lower jaw & ST for the upper jaw.
Headache, especially frontal, sinus (yangming area).
Chronic pain.
Influence the circulation of Qi and blood - use the four gates, LI 4 & LV 3 to strongly move the Qi and blood in the body clearing stagnation and alleviating pain.
Promote labor or for retained placenta.

LI 10 (Shoushanli)Location: 2 cm below LI 11 on the LI 5 to LI 11 line.

Actions and effects:
The following relationships exist between the ST and the LI and can be used to treat ST, LI and SI organ problems.
SI: LI 8 & ST 39.
LI: LI 9 & ST 37.
ST: LI 10 & ST 36.
Shoulder, elbow and wrist pain issues, general aches in these areas.
Less dispersive and more tonifying than other LI points.
Epigastric and abdominal pain, ulcers, vomiting.

Location: 2 cm below LI 11 on the LI 5 to LI 11 line.

SP 6 (Sanyinjiao)Location: 3 cm directly above the tip of the medial malleolus on the posterior border of the tibia.


Precautions: no needle in pregnancy

Point associations:
Intersection point of the SP, LV and KD (3 leg yin meridians)

Actions and effects:
Tonify Yin and blood, all spleen disorders.
Digestive disorders, sinking or prolapse.
Gynecological issues, male sexual issues, difficult labor (expel fetus).
Bleeding disorders, cool blood in hot skin diseases.
Insomnia and other anxiety related emotions.

SP 8 (Diji)Location: 3 cm below SP 9 on line connecting SP 9 and the tip of the medial malleolus.

Point associations:
Xi Cleft point.


Actions and effects:
Xi Cleft point - acute and painful menstrual issues due to blood stagnation - clotting, fibroids, dysmenorrhoea.
Male infertility.

SP 10 (Xuehai)Location: with knee flexed, 2 cm above the superior medial border of the patella on the bulge of the medial portion of quadriceps femoris (vastus medialis).

Actions and effects:
Any gynaecological issues originating from blood, heat, stasis and/or deficiency - irregular menstruation, cramping, PMS.
Skin problems from damp-heat or hot blood.

ST29 (Guilai)Location: 2 cm lateral to the AML level with CV 3.

Actions and effects:
Excess or cold/deficient disorders of the lower warmer - amenorrhoea, irregular menstruation, qi stagnation/masses.
Running Piglet disorder.

ST36 (Zushanli)Location: 3 cm below ST 35, one finger width lateral from the anterior border of the tibia.

Point associations:
He Sea point
Lower Lower He Sea point of the ST
Earth point
Sea of Water and Grain point
Command point of the abdomen

Actions and effects:
Tonify deficient Qi or blood.
Tonify Wei Qi.
All issues involving the stomach or the spleen.
Clear disorders along the course of the channel - breast problems, lower leg pain.
Earth as the mother of Metal - will support lung function in cases of asthma, wheezing, dyspnoea.
Psychological/Emotional disorders - PMS, depression, nervousness.

PC6 (Neiguan)Location: 2 cm above the wrist crease between the tendons of palmaris longus and flexor carpi radialis.

Point associations:
Luo Connecting point
Yin Wei Master point coupled with SP 4

Actions and effects:
Similar to PC 3 but more for chronic heart symptoms from Qi stagnation.
Opens and relaxes the chest, chest tightness, asthma, angina, palpitations.
Insomnia, other spirit disorders of an excess or deficient nature, mania, nervousness, stress, poor memory.
Nausea, seasickness, motion sickness, vomiting, epigastric pain.
Carpal tunnel syndrome.

Ren 3 (Zhongji)Location (zhongji): 1 cm superior to qugu. Regulates LR, warms KI, irregular menses.

RN 4 (Guanyuan)Location: 1.5 cm lateral to the Du meridian, at the level of the lower border of the spinous process of the 5th lumbar vertebra.

Indications
Low back pain, abdominal distension, diarrhoea, enuresis, sciatica, frequent urination.

Traditional action
Strengthens the lower back, removes obstructions from the channel.

RN6 (Qihai)Location: 1.5 cm lateral to the Du meridian, at the level of the lower border of the spinous process of the third lumbar vertebra.

Indications
Low back pain, irregular menstruation, dysmenorrhoea, asthma.

Traditional action
Strengthens lower back, removes obstructions fro mchannel, regulates Qi and blood.

KI 3 (Taixi)Location: in the depression between the medial malleolus and tendo calcaneus, at the level with the tip of the medial malleolus.

Indications
Sore throat, toothache, deafness, tinnitus, dizziness, spitting of blood, asthma, thirst, irregular menstruation, insomnia, nocturnal emission, impotence, frequency of micturition, pain in the lower back.

Traditional action
Tonifies the kidneys, benefits essence, strengthens the lower back and knees, regulates the uterus.

KI 11 (Henggu)Location: 1.5 cm posterior to Wuchu (UB 5), 1.5 cm lateral to the Du meridian.

Indications
Headache, blurring of vision, nasal obstruction.

Traditional action
Clears heat and eliminates vexation, brightens the eyes and opens the portals.

TE 5 (Weiguan)Location: 1.5 cm lateral to the lower border of the spinous process of the eighth thoracic vertebra.

Indications
Diabetes, vomiting, abdominal pain, pain in the chest and hypochorondriac region.

Traditional action
Relieves stagnation of blood.